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Fragmented care and perverse incentives behind sharp rise in knee arthroscopies

Rates in Scotland have risen 4% compared with 69% in England over comparable period, analysis shows

Caroline White

Thursday, 24 September 2015

The fragmentation of care and emphasis on the “commoditisation of treatment” are behind the sharp rise in keyhole surgery for knee joint problems in England compared with Scotland, finds an analysis* published in The BMJ today.

Although arthroscopic surgery has been widely used to treat knee osteoarthritis for more than 20 years, there is little evidence to suggest that it works. And current NICE guidance says that referral for arthroscopic lavage and debridement should only go ahead if there is a clear history of mechanical locking, say the researchers.

Given the parlous state of NHS finances, the researchers assessed patterns of use in England and Scotland to tease out possible explanations for any differences between the two countries.

They re-evaluated data from a recent analysis of hospital episode statistics, which suggested that rates of arthroscopy among the over 60s in England between 2000 and 2011 had fallen.

This showed that there had been an overall increase in procedures from 185 per 100,000 of the population to 267/100,000, equivalent to an increase of 69%.

But the equivalent figure for Scotland was only 4%, with rates rising from 111/100,000 of the population among those aged 60 to 74 in 2000 to 115/100,000 in 2013.

Most of the increase in England was attributed to a rise in meniscal resection, particularly between 2007 and 2010. This is despite no evidence of a substantially increased prevalence of meniscal tears in this age group, or an equivalent rise in Scotland.

The researchers point out that the “huge increase” has resulted in rates that resemble those of health economies in Australia and the US, which are based on private insurance—200 procedures/100,000 of the population.

Their analysis indicates that patterns of service delivery in Scotland are more akin to those recently recommended in the report on reforming the payment system for NHS services, and published by the regulator Monitor.

This advocates that specialist providers should be encouraged to set up networks delivering coordinated services that embrace the full continuum of care from diagnosis to treatment to support for ongoing self care, and that local outcomes data should be included in the standard contract.

“The fragmentation of care and commoditisation of treatment have created perverse incentives to overtreat,” the researchers conclude.

“A single point of clinical responsibility for the total care pathway, with success determined by patient outcome and not volume, seems to be key to achieving appropriate rates of investigation or treatment.”


* Hamilton D F, Howie C R. Knee arthroscopy: influence of systems for delivering healthcare on procedure rates. BMJ 2015;351:h4720. doi: 10.1136/bmj.h4720

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